System for manipulation and display of medical images

ABSTRACT

A system for manipulation and display of medical images, comprises an interpretation unit comprising a computer system with an image display unit(s) providing a main viewer and at least one auxiliary clipboard viewer; and a handheld controller. The controller has finger operated dictation and display controls to operate display a series of images in the main viewer. Dictation may be entered in a microphone contained in the controller and digitally recorded in the computer system. A hand held controller for selecting an image displayed in the main viewer and displaying the image in the clipboard viewer are provided to permit assembly of summary studies of medical images, display of side by side comparisons of different series of images. The stored dictation may be synchronized with the images displayed at the time of dictation to provide for a multimedia playback of the dictation and images.

This application is based on, and I claim priority rights under 35U.S.C. §119(e) from, U.S. Provisional patent application Ser. No.60/021,359, filed Jul. 8, 1996.

FIELD OF THE INVENTION

The present invention relates generally to the field of computerizedimage acquisition, management and display in medical applications, andmore particularly to the field of radiology equipment.

BACKGROUND OF THE INVENTION

Radiographic images, such as X-ray films, and Magnetic resonance imaging("MRI") and computerized tomograph (CT) transparencies havetraditionally been reviewed by a diagnosing physician such as aradiologist on a film viewer, on which a series of images in a patientstudy are displayed in groups of two or more. Different image series,generated by processing the data captured during a patient scan indifferent ways, are typically provided. The different image series maydisplay the same portions of the patient's anatomy but processingreduces the amount of information in the image to allow for films havingsufficient pixel depth to provide the detail needed for diagnosis in thetissue of interest. The film viewer may be a static light box or amotorized film viewer. A motorized film viewer consists of verticallypositioned light boxes and an endless belt on which the films aremounted and which passes the films in front of the light boxes.Motorized film viewers are controlled by the radiologist using footpedals which activate the motorized viewer to cause the films to bemoved to the left or to the right (or in some cases, up and down) topermit viewing of the desired portions of the film series. The imagesare usually presented in a standard sequence, usually in the order ofimage capture. The radiologist will typically dictate a medical studyinto a tape recorder while viewing the films, for later transcription.The films and transcribed dictation are stored in a patient's file.

Filmless image systems have also been proposed and used. Filmlesssystems have been used in connection with handling both MRI images, andcomputer tomography images generated by processing X-ray image data togenerate a series of "slices" through the human body. Such systemshistorically have presented all the image data captured by the MRI ortomography equipment, as opposed to in film images (where the medicaltechnician will expose films only for selected series of images ofclinical interest). This mass of information has proven unwieldy toreview and consider, as instead of filtering the image data through theselection of a skilled technician, all the image data is presented tothe diagnosing physician. Another disadvantage of this approach is thatit does not provide an "image of record," that is, the basic image(s)relied on by the physician in making the diagnosis. Given thelimitations of the image processing equipment, it took a significantamount of time to review the numerous image series. Such systems are farless efficient than the conventional light boxes, which allowed theradiologist to rapidly review numerous series of images to find the fewimages showing the pathological condition of interest. Other filmlesssystems have been proposed in which a series of images are presented tothe diagnosing physician simultaneously. One such system is described inHilton, U.S. Patent No. 5,452,416.

However, all of these systems have proven awkward in actual use, as theyrequire use of mouse, keyboard, trackball or other device to navigatethrough the image series. These control devices severely impair thediagnosing physician's ability to concentrate on the images presentedand to relate the images to his knowledge built up through years ofpracticing medicine. The constant need to correctly position and actuatea mouse and trackball to navigate through images has made the use ofsuch systems far less efficient than conventional film systems. Inconventional film systems, the image navigation is effortless, requiringno more than movement of the eyes over a wall filled with film images,allowing the diagnosing physician to concentrate on the real work ofinterpreting the medical images to reach a diagnosis. Such controldevices thus limit the fluid navigation by the diagnosing physicianthrough the image series, and tie the physician to a single position.These control devices are also awkward for a diagnosing physician whomay need to refer to materials such as textbooks or prior film-basedmedical studies for comparison. These devices also may impede thephysician's ability to easily dictate the medical study, as mostdictation equipment requires a handheld recorder or microphone, thusrequiring the physician to either put down and pick up the microphoneeach time he needs to activate the mouse or trackball to see furtherimages. Alternatively, the physician might learn to work two handedly,but this creates additional complications, for example, if the physicianalso desired to turn pages in or otherwise refer to a text or otherreference material.

SUMMARY OF THE INVENTION

It is an object of the invention to provide a apparatus and method forannotation and navigation of electronic images and documents thatincreases the diagnosing physician's efficiency in using the system.

It is an object of the invention to provide such an apparatus that canbe operated single handedly. It is an object of the invention to providesuch a system which permits the diagnosing physician to move around in awork area to retrieve reference works, view past studies, or do otherthings while at the same time continuing with the medical study of theimages.

These objects, and other objects as disclosed in this application, areachieved by an apparatus for audio dictation and navigation ofelectronic images for use with a personal computer system. The computersystem is provided with at least one image display unit, random accessmemory, means for digital data storage, and an analog to digitalconversion system. The apparatus comprises a handheld wirelesscontroller having a combination of controls serving as an image controlactuator and a dictation actuator. The image control actuator isoperable to transmit wireless control signals to a wireless controlsignals receiving unit operably connected to the computer system tocause the computer system to display each one of a series of electronicimages, in sequential order, and to select display of each next image ornext preceding image, and to cause display of related image series insequential order, and to select display of each next image series ornext preceding image series. The dictation actuator is operable toactivate wireless transmission of voice signals, generated by amicrophone, to a wireless voice signals receiving unit operablyconnected to the computer system to cause the computer system to convertthe voice signals to digital signals and to record the digitized voicesignals as digital audio files in the means for digital data storage,and to permit selective playback of such files. Further details of theinvention are described below.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing aspects and other features of the invention are explainedin the following description, taken in connection with the accompanyingdrawings, wherein:

FIG. 1 is a top rear perspective view of a handheld apparatus for audiodictation and navigation of electronic images and documents inaccordance with one embodiment of the invention.

FIG. 2 is a top rear perspective view of a handheld apparatus for audiodictation and navigation of electronic images and documents inaccordance with another embodiment of the invention.

FIG. 3 is a bottom front perspective view of the handheld apparatus foraudio dictation and navigation of electronic images and documents ofFIG. 2.

FIG. 4 is a front schematic illustration of computers of aninterpretation unit for use with the handheld apparatus of FIGS. 1, 2and 3.

FIG. 5 is a front elevation view of an embodiment of an interpretationunit.

FIG. 6 is a top plan view of the monitors of an interpretation unitpositioned for use by a single person.

FIG. 7 is a top plan view of the monitors of an interpretation unitpositioned for use by multiple persons.

DETAILED DESCRIPTION OF THE INVENTION

Referring to FIGS. 1-7, where like numbered elements in the drawingsrepresent the same elements, a handheld controller 20 for audiodictation and navigation of electronic images and documents is shown inFIG. 1, and another embodiment of such a controller is shown in FIGS. 2and 3 as 120.

Controllers 20, 120 comprise two significant control subsystems. Animage control subsystem permits navigation among the images to bedisplayed by a viewing unit. A dictation subsystem operates to receivevoice dictation. Preferably, a wireless transmitter subsystem transmitscommands from the image control subsystem and the dictation controlsubsystem to a personal computer based interpretation unit 22.

Referring now to FIGS. 4 and 5, the interpretation unit 22 is preferablyprovided with at least one conventional personal computer or workstationsystem 80. Most preferably, interpretation unit 22 comprises threeconventional personal computer systems 80 which are linked together by anetwork system. Each personal computer system 80 is preferably aconventional personal computer such as an Intel processor based systemrunning a Windows 95 or Windows NT operating system. Each personalcomputer system 80 includes an image display unit 82 such as a 20 inchby 20 inch 0.28 dpi non interlaced monitor, random access memory(preferably a minimum of 32 megabytes, and more preferably 128megabytes), means for digital data storage such as a hard disk drive,and an analog to digital conversion system for converting analog audiosignals to digital format. The use of three linked personal computersprovides a simple and effective way of driving three separate monitors,which can be independently controlled by the handheld controllers 20,120 or which can be controlled by the handheld controllers 20, 120 via aselected "master" personal computer 84, with the flanking left personalcomputers 86 and right personal computer 88 acting as "slave" computersunder the control of the "master" computer 84.

In the present invention, various fields of view are contemplated,including a main viewer 90, a left clipboard viewer 92, and a rightclipboard viewer 94. As described below, the main viewer 90 will displayan image which is then being studied, and the left and right clipboardviewers 92 and 94 serve auxiliary display functions.

In an embodiment of the interpretation unit 22 in which three personalcomputers are networked together, the monitor of the master computer 84acts as the main viewer 90, the monitor of the left slave computer 86will act as a left clipboard viewer 92 and the monitor of the rightslave computer 88 will act as the right clipboard viewer 94. However,the viewers 90, 92 and 94 may also be implemented as separate windowsdisplayed on a single monitor if interpretation unit 22 comprises asingle personal computer or workstation. In addition, since patientmedical images at this time generally consist of black and white images,it would also be possible to implement the three viewers as separatemonitors driven by a single personal computer or workstation byappropriate software to drive each monitor in one of the R,G,B (red,green, blue) channels of the RGB color model.

In a preferred embodiment, the three monitors of interpretation unit 22are mounted on a pivoting mountings, as shown in FIGS. 6 and 7. Thepivoting mountings position the main viewer monitor 90 in a centralposition, with the left and right clipboard viewer monitors 92 and 94angled inwardly to provide a convenient viewing of all three monitorssimultaneously, as shown in FIG. 6. The pivoting mountings are alsodesigned so that the left and right clipboard viewer monitors may bepivoted outwardly, to allow for use of the left and right clipboardviewer monitors 92 and 94 as separate main viewers by other medicalpersonnel, as shown in FIG. 7.

Interpretation unit 22 will have installed in it a "Viewer" applicationsoftware running on Windows 95 or Windows NT that responds to thediagnosing physician's use of the controllers 20, 120 to implement thecommands transmitted from controllers 20, 120. Where interpretation unit22 consists of three separate computers, each computer will have the"Viewer" software loaded on it, allowing each computer and itsassociated monitor to be simultaneously used by different persons ifdesired. The use of separate computers with "Viewer" software providesbackup systems in the event of the failure of the "master" computer 84.

In the expected environment of use, the interpretation unit 22 will havereceived a digital "folder" for the patient to be diagnosed. The"folder" will contain patient identifying information, a patient medicalhistory and/or chart; and a series of digital images to be reviewed bythe diagnosing physician. Unlike current filmless systems, the patientimages stored in the folder will be images selected by a skilledtechnician in the same way as is now done in conventional radiology filmsystems. The images in the patient file will be captured at the MRI orother imaging unit by placing a suitable digitizing tablet in thelocation where films are exposed by the technician. The exact sameprocedures as in selecting images for film exposure will apply to thefilmless images to be captured for use in the present invention. Thedigital images are preferably provided in a bitmap format, althoughother formats may be used.

The patient "folder" will typically be named with the name of thepatient, e.g. "John Smith." The interpretation unit 22 may receive suchpatient information via a hospital network, or a modem transmission, ordirectly from an image capture device such as a MRI unit.

Controller 20 uses a pistol grip with a control end 26 located in anupper end, similar in appearance to a computer joystick used for playingcomputer games. Controller 120 is a more elongate handheld device with acontrol end 26 at one end. In the specification following the term"controller 20" shall be used to refer to both controllers 20 and 120,as the functions thereof are identical, the sole difference being intheir shape.

Controller 20 is preferably shaped to be comfortably held in one hand.At control end 26 of case 24 are provided the controls for operating theimage control subsystem and the dictation control subsystem.

In the preferred embodiment, the controller 20 has only four switchelements or assemblies to operate as the dictation control and the imagedisplay control: a trigger switch 42 located at the underside 28 ofcontroller 20; a pressure switch 44 located on the upper surface 29 ofcontroller 20; and a left toss button 46 located on the upper surface 29of controller 20 to the left of pressure switch 44; and a right tossbutton 48 located on the upper surface 29 of controller 20 to the rightof pressure switch 44. With reference to FIG. 1, the trigger switch 42is located where it may be actuated by the forefinger of the user, whilethe pressure switch 44 and the left and right toss buttons are locatedon the upper surface of controller 20 where they may be actuated by theuser's thumb. These four switch elements or assemblies provide allnecessary inputs to achieve the navigation of images and dictationcontrol. If desired, of course, additional buttons and controls may beadded, but it is expected that a minimum of controls will provide themost reliable and user friendly control. The present invention desirablyhas no more than six switch elements or assemblies for operation of allnecessary functions. The reduction of controls is achieved in thepresent invention by allowing for different types of inputs to eachswitch assembly, such as double clicking or pressure sensitive switches,that allow for different outputs for each input. This is also achievedin the present invention by providing for the different switchassemblies to operate different functions depending on the current modeof operation of the image display and the audio dictation, orcombination thereof, at the time of the input to the control.

It is to be appreciated that other switch elements may be substitutedfor the preferred switch embodiments described above in connection withthe controller 20. For example, in an alternative embodiment, thefunctions of pressure switch 44 and left and tight toss buttons 46 and48 described below may be implemented in a joystick type control that ismovable from front to back and left to right, or by a four way rockerswitch, or a thumbwheel, or a tiny trackball, or a sensitive touchpad,or set of directional arrow keys located in the controller 20. Suchvariations are all within the scope of the invention.

In addition to the control switches 42, 44, 46, and 48, controller 20 isprovided with a microphone 50 to receive voice dictation and convert thedictation to appropriate electrical impulses. In another embodiment,controller 20 may have a jack 52 for receiving a clip-on microphoneinstead of, or in addition to, the microphone in the controller 20.Microphone 50 is preferably located on the upper surface 29 ofcontroller 20 at its control end 26.

Controller 20 may be attached to interpretation unit by suitableelectrical cabling, however, in the preferred embodiment, controller 20is a wireless unit that remotely communicates with interpretation unit22. Such wireless systems are known in the art and may include radiofrequency, infrared, or other wireless communications systems.Preferably, controller 20 is provided with a infrared transmitter 52 atits control end 26 for communication with the interpretation unit 22. Insuch case, the various keyboard interrupts and/or mouse interruptsgenerated by the controller 20 are communicated via modulated infraredbeams transmitted from the infrared transmitter 52 to infrared receivers54 associated with the computers or workstations of interpretation unit22 to cause the desired actions. In addition, voice dictation receivedin microphone 50 and converted to electrical signals are alsocommunicated from the infrared transmitter 52. If desired, a singletransmitter 52 may serve to communicate both the control signals and thedictation signals to the infrared receiver, or separate infraredtransmitted may be used. In a wireless embodiment, controller 20 isprovided with a power source such as suitable batteries to power thefunctions of the controller 20.

The control switches 42, 44, 46 and 48 generate keyboard interrupt andmouse control signals that control the interpretation unit 22. Suchkeyboard interrupt and mouse control signals are conventional signals inoperation of personal computer operating systems which are generated,respectively, upon the entry of particular keystrokes or clicking themouse buttons. In a conventional system, for example a Microsoft Windowsoperating system, event routines are actuated upon pressing a keyboardkey as follows: the keyboard chip transmits a message, that a key orcombination of keys are pressed, to a buffer, which notes the key andtransmits a message identifying an "onkeydown" routine and the key orkey combination pressed to the operating system. The operating systemsreceives this message and posts a message to all open programs when akeyboard interrupt is received; and the program which is the activeprogram (known as the program which has the "focus") responds to thekeyboard input. Upon release of the key on the keyboard, the key chiptransmits another key indication; the buffer notes the key and transmitsa message identifying an "onkeyup" and the key or key combinationpressed to the operating system, which then again transmits this messageto all open programs, and the active program responds thereto. In thepresent invention, the controller switches actuate such keyboardinterrupts to instruct a "Viewer" application software running on one ormore of the master and slave computers 84, 86, and 88.

It is to be appreciated that with the present invention, the controller20 is intended to be the only necessary control, and thus theconventional keyboard and mouse controls may be omitted from thepersonal computers that constitute the interpretation unit 22. However,of course, if desired, such interface devices may be included in theinterpretation unit 22, as for example, if the present invention isimplemented in a single computer at a medical office where the computermay be used for other functions besides review of medical images fordiagnosis. However, it is expected that when the "Viewer" software foroperation of the personal computers in their function as aninterpretation unit 22 is running, that the controller 20 will be theonly interface device necessary for a diagnosing physician's control ofthe interpretation unit 22 to review patient images and to dictate amedical study.

In one preferred embodiment, the following switches and combinations ofswitches actuate the following functions. However, of course, thevarious functions described below may be assigned to other switches orcombinations of switches than described in connection with the preferredembodiment, such different assignments being all within the scope of theinvention. As described below, image display control and the dictationcontrol have multiple functions, and at least some of the functions ofthe image display control and the dictation control are bothaccomplished through commands generated by actuation of one or more ofthe switches. The particular control function provided by a switch orcombination of switches is dependent on the mode of dictation or mode ofimage display or combination of modes of dictation and image display atthe time of operation of such one or more switches.

The trigger switch 42 actuates the primary functions of the voicedictation system. If the trigger switch 42 is clicked and held down, themicrophone 50 is connected to a power source, and a keyboard interruptis sent to the interpretation unit 22, where the "Viewer" softwaresummons the "audio record" function, and voice dictation by thephysician into the microphone is communicated to the interpretationstation 22 and is recorded as a digital file.

Recording continues until the trigger switch 42 is released, which istransmitted as a keyboard interrupt that causes the "Viewer" software tosummon a "stop audio record" function. A hold down of the trigger switch42 will initiate the record function whether in stop or playback mode.

The audio record function, as well as rewind, playback and other audiofunctions described herein are conventional features in the Windows 95operating system and are not described in detail herein. It is notedthat a sound card will be required to cause the analog to digitalconversion needed to store the voice dictation as a digital file. Voicedictation received by the interpretation unit 22 is stored as a Windows".wav" file for playback using the conventional Windows based audiosoftware. The file may be stored locally on the interpretation unit 22or in a network file server as selected.

The "Viewer" software will automatically save the voice dictation fileeach time the trigger switch 42 is released. The "Viewer" software willautomatically save voice dictation file under a file name such as "StudyDictation.wav." The file will preferably be automatically saved in thepatient "folder."

When the audio system is in neither the record nor playback, if thetrigger switch 42 is clicked and released, the playback function isactivated. In the audio file currently open by the "Viewer" software,the recorded audio file will back up two seconds from the end of thefile and then will playback that portion of the file to the end. Whenthe recorded audio file is being played back, actuation of the triggerswitch 42 by a click and release stops the playback. Also, when therecorded audio file is being played back, actuation of the triggerswitch 42 by two clicks and release causes the "Viewer" software to jumpto the end of the recorded audio file.

When the audio system is in neither the record nor playback, if thetrigger switch 42 is clicked twice it will initiate a "rewind" sequence,in which the position in the audio file is moved back, with accelerationafter an initial period of "rewind". "Rewind" may be halted by clickingtrigger switch 42 once.

When the audio system is in playback mode, as a result of a single clickof trigger switch 42, toss buttons 44 and 46 can be used to calladditional audio dictation functions. For example, the left toss button44 can be used to toggle through various dictation functions (with ascreen display in a small window showing the various functionsselected). These functions preferably include (1) insert additionalaudio; (2) overwrite audio; and (3) delete audio. Once a dictationfunction is selected, the right toss button 46 may be clicked during thedesired position in playback to mark the position of the desiredfunction, and clicked a second time, where applicable, to mark the endof the function. Thus, where insert additional audio is desired, theright toss button 46 will mark the position of the audio insert; and thetrigger switch 42 may be activated to record the audio insert. Whereoverwrite audio is desired, the right toss button 46 may be clicked tomark the beginning of the portion of the audio file to be overwritten,and clicked again to mark the end of the portion to be overwritten, andthe trigger switch 42 may be activated to record the audio insert to theoverwritten portion. Where delete audio is desired, the right tossbutton 46 may be clicked to mark the beginning of the portion of theaudio file to be deleted, and clicked again to mark the end of theportion to be deleted.

Other dictation switch designs may also be used in the handheldcontroller 20. For example, the dictation control switch may be a slideswitch actuated by forward and rearward motion. In such an embodiment,the standard dictation controls (record, off, play, fast forward,rewind) are actuated by positioning the slide switch along thelongitudinal axis of the controller 20. Thus, recording is actuated bypositioning the slide switch at the forward position of its travel.Moving the slide switch backwardly actuates the following modes, inorder: stop, playback, fast forward, and rewind. Other switch controlsystems may also be implemented in accordance with the invention.

The audio file comprising the diagnosing physician's dictated study ofthe patient images may be converted to a text file by a transcriptionistor by use of voice recognition software. At the time of the presentinvention, it is expected that a transcriptionist will be required toaccurately transcribe the dictated study. However, as vendors such asIBM and others continue to improve voice recognition software, that theservices of a transcriptionist may be less needed, and that voicerecognition software may be used to convert the recorded audio file to atext file.

In a system using a transcriptionist in a distributed network, a centralfile server will maintain information on the status of the patientfolder and the contents thereof, and will forward a copy of the audio toa transcription station to generate the corresponding text file.

The controller 20 also controls the "Viewer" software to permit thephysician to review the images of the patient. Pressure switch 44 is theprincipal control for the image viewing system. Pressure switch 44 is astrain gauge switch that transmits different keyboard keys as keyboardinterrupt instructions to the interpretation unit 22 depending on theamount of pressure applied to the switch. In the preferred embodiment,pressure switch 44 is a thumb actuated rocker bar switch that has adefault centered position, and which may be pushed forwardly or pulledbackwardly, against a bias that will tend to center the pressure switchin its centered position. Forward pushing on the edge 45 of switch 44will cause the Viewer software to advance through the image series.Backwards pulling thereon will cause the Viewer software to back upthrough the image series. The different keys transmitted by pressureswitch 44 instruct the interpretation station 22 to advance or back upthrough and display the image series at different speeds.

The image series stored in the patient folder in interpretation unit 22is preferably stored as multiple files, identified for example as100010001, 100010002, where the terminal four digits identify the numberof the image in the series, and the second through fifth digits indicatethe number of the series. Actuation of the pressure switch 44 by asingle push will cause the Viewer software to display each image file innumeric order, one image at a time, beginning from the first image ofthe first series. Actuation of the pressure switch 44 by pushing andholding the pressure switch 44 will cause the Viewer software to scrollthrough the images. The amount of pressure applied to pressure switch 44will control the speed at which the Viewer software scrolls through theimages in the series. The scrolling of images will halt when the end ofan image series is reached (or the end of the set of all images reviewedduring the study so far), whereupon the first image of the next serieswill be displayed, and the scrolling function will be terminated. Theuser may then step or scroll through the displayed next image series byagain activating the pressure switch 44. In the preferred embodiment,the physician will be required to step through the entire sets of imageseries before rapid scrolling will be permitted. This will help toinsure that each image is reviewed initially, to prevent missing apotentially relevant image during rapid scrolling.

A serial display as described above is believed to be the most effectiveway of presenting the images in the patient file, as it maximizes thediagnosing physician's ability to interpret the image using lower cost,standard size computer monitors. However, it is also possible to presentthe image information in a matrix format with multiple images displayedin a monitor at one time. Such multiple images may comprise a tiled setof windows, each containing a separate image. In such case, the controlsof controller 20 will be as described above, except that in stepping orscrolling through images, the Viewer program will step through thedifferent windows.

However, it is believed that a serial display provides a preferableapproach as it will force the physician (particularly the experiencedphysician) to review all the images presented, without the possibilityof skipping over a potentially relevant image. With an experiencedphysician there is sometimes a temptation to leap to the most relevantimage--and to reach the obvious diagnosis. With a serial display, aphysician will be less likely to miss the less obvious diagnosis thatmight be reached after proper review of all images. The serial imagedisplay is also helpful to the inexperienced physician who will have abetter awareness of the entire image set, and what he is looking at, byvirtue of the preceding images already displayed. A final benefit of aserial display approach (as opposed to a multiwindow format) is that itallows presentation of a large image. In comparison to film, which has aquality of very high contrast resolution at a certain luminance, currentmonitors provide much less resolution. To compensate for the reducedcontrast resolution, the spacial resolution is enhanced (the image ismade larger) to give the user an image of subjective quality thatapproaches the resolution provided by film.

The "Viewer" software will also determine if the user has displayed aspecific image for a predetermined period of time. If so, the Viewersoftware will "bookmark" for subsequent return. The "bookmark" may beinserted by adding an appropriate stop in the patient image file, or ina table containing a list of the images, or by storing the filename ofthe displayed image for later recall. Thus, if the diagnosing physicianstudies the third image in a first series for a period exceeding thepredetermined period of time, then steps forward to the third image ofthe next series, the physician may jump back to the third image of thefirst series by pulling back on the pressure switch 44. The "Viewer"software, having bookmarked the third image of the first series, willstop backwards scrolling when that image is displayed. In anotherembodiment of the invention, images studied for a predetermined periodof time may be selected to be automatically tossed to one of theclipboard viewer monitors; and/or tossed images may be auto-bookmarked.

As mentioned above, interpretation unit 22 preferably comprises threeseparate networked personal computers or workstations, operating a mainviewer monitor 90, a left clipboard viewer monitor 92, and a rightclipboard viewer monitor 94. In a default mode of operation, the mainviewer monitor 90 will have displayed on it the selected displayed imagein an image series. The left clipboard viewer 92 will be set up todisplay a number of images in a tiled format, for example, in a 2×2matrix of tiled images. Other matrix sizes may be used, however, forbetter image clarity, a 2×2 matrix size is preferred. A title block willbe associated with each displayed image to identify the filename of theimage.

The toss buttons 46 and 48 serve two functions. A quick click of a tossbutton 46 or 48 causes the image currently on view on the main viewermonitor 90 to be separately displayed on the respective clipboard viewermonitor 92 or 94. This is again accomplished by the toss buttongenerating a keyboard interrupt with instructs the "Viewer" program todisplay the selected image on the selected clipboard viewer monitor, forexample, by copying the image to a new file containing images ofinterest, and displaying the new file. The use of the toss buttons 46and 48 in this manner also marks the "tossed" image for later use of thecomparison function described below. An image that has been "tossed" toa clipboard viewer monitor may be "untossed" (removed from the clipboardviewer) by clicking the toss button for the clipboard viewer when themain viewer monitor 90 has displayed on it the image to be "untossed".

It is anticipated that the right clipboard viewer will generally be usedfor assembling a summary study containing images of particular medicalinterest, while the left clipboard viewer will be used as a worksheetfor displaying side by side comparisons of different series, or displayof prior patient studies for comparison (or consultation as neededwithout interruption of the present study).

If a toss button 46 or 48 is pressed and held down, it will invoke a"mode selection" function in the main viewer program. The "Viewer"program will display a menu of the various modes on the main viewermonitor or one of the clipboard monitors. In the "mode selection" mode,the pressure switch 44 may be used to cycle through the various modes,accompanied by a display in which a highlighted selection bar down themenu of modes. A mode may then be selected by clicking on the tossbutton again. Of course, other control schemes may be implemented usingthe controller 20, for example, upon entering a "mode selection" mode,the toss buttons could be used to cycle through the various modes byclicking the toss buttons to cycle one entry at a time through thevarious modes, and selection could be made by clicking the triggerswitch 42; or the trigger switch 42 could be used to cycle through thevarious modes and the selection could be made by pressing one of thetoss buttons. If the toss buttons are used to cycle through the variousmodes, one toss button will cycle up through the mode selection menu andthe other toss button will cycle down through the mode selection menu.In another embodiment, one toss button might be used to cycle throughthe mode selection menu and the other toss button would be used toselect the particular mode to be implemented. Other mode selection andselection schemes are equally within the scope of the present invention.

The "modes" to be selected from may include one or more of the followingfunctions.

(1) List Patients mode. This will cause the system to display thepatient folders so that the folder of a patient to be studied can beselected.

(2) View mode. This will cause the system to return to the defaultviewing mode with controller 20 controlling the master computer 84 ofthe interpretation unit 22.

(3) Compare mode. This will cause one clipboard viewer (preferably theleft clipboard viewer monitor 92) to display a side-by-side presentationof all images in two series starting with the first marked image in eachseries. For example, while in view mode, a diagnosing physician couldselect the third image of the second series and send it to the leftclipboard viewer 92 by marking with toss button 46, and could thenselect a fourth image of the fourth series and send this image to theleft clipboard viewer 92 by marking with toss button 46. The imageswould then be displayed with the third image in the second series in thetop left quadrant of the monitor screen, and the fourth image of thefourth series in the top right quadrant of the monitor screen. Thediagnosing physician would then summon the compare mode, which wouldcause the display of all subsequent images to the selected images in aside by side relationship, with the selected images on top, and thesubsequent images below.

(4) Annotate mode. The master computer 84 may be set up with a lightpen, allowing the diagnosing physician to annotate the patient imagedisplayed on the main viewer 90. The annotated image may then be savedas a separate file from the original image by using toss button 48 tosave it to the right clipboard viewer 94, or upon return to view mode.Screen buttons actuated by the light pen may be provided to step forwardor back through the image series and to "toss" an annotated image to theleft or right clipboard. A submenu may also be established to select theparticular image to be annotated.

(5) Left clipboard control. This will cause the controller 20 to beacting on and controlling the left clipboard viewer monitor 92. Thus forexample, after invoking the compare function described above, thediagnosing physician could then select left clipboard control and usethe controller 20 to step up and down or scroll up and down through theside by side comparison, using the pressure switch 44 and the navigationcontrol.

(6) Right clipboard control. This will cause the controller 20 to beacting on and controlling the right clipboard viewer monitor 94.

(7) Dictation special functions. This menu selection will call a submenuwith the insert, overwrite, and delete the dictated audio file functionsdescribed above.

(8) End study. This will cause the system to close the open files beingviewed, and the dictated audio file, and to save the summary studyprepared by the diagnosing physician as a separate file or files.

Other modes might include a main menu mode, to call a main modeselection menu, if, for example, some or all of the above functions oradditional functions are established as submenus to be selected; and aMark image mode to bookmark the image currently on display in the mainviewer, or to bookmark other images as may be selected from a submenu,to subsequently implement comparison and other functions. The light penmight also be used by a non-physician technician to operate variousother functions of the computer.

When series of images in a patient study is first opened, the clipboardsmay be used to provide an overview of the study. For example, the leftand right clipboard viewers 92 and 94 might first have displayed in themthe center image of each series of images. Other modes of initialdisplay may be provided, such as the first and last image of a series,or all of the images in one or more series in the patient image file. Insome patient image studies, there is a "scout slice", which is anorthogonal view of the patient anatomy of interest showing the locationof the various slices constituting the image series. Where a scout sliceis available, it will preferably remain on display, most preferably asthe last image on display on the left clipboard viewer monitor 92.

Upon tossing of a first image to a clipboard viewer monitor by the tossfunction, the initial image display will be cleared. Thus for example,upon invoking the toss function to transfer a copy of the image on themain viewer monitor 90 to the right clipboard viewer monitor 94, theimages placed on the right clipboard viewer monitor 94 at initialstart-up will be cleared. As noted, it is anticipated that the rightclipboard viewer 94 will generally be used for assembling a summarystudy containing images of particular medical interest, and may includeannotated images as described above, while the left clipboard viewer 92will be used as a worksheet. When the summary study is completed, itwill be saved as a separate file from the original patient study. It isalso possible to save the summary study in the form of a list specifyingthe images of particular interest from the original, complete, patientimage file. The summary study images will typically be the imagespertinent to the medical diagnosis, and may printed, and/or deliveredback to a referring physician along with the text file comprising thedictated patient study, either in electronic or hard copy form.

The clipboard viewer monitors may also be used for a comparative imagedisplay as described above.

The clipboard viewers 92 and 94 also serve other functions. As notedabove with regard to the master computer, one slave computer 86 or 88may be set up with a light pen, allowing the diagnosing physician toannotate the patient image displayed on the clipboard viewer. In suchcase, the patient image will most likely be displayed in a full sizeimage, rather than in a tiled matrix of smaller images, although, ofcourse, such a smaller format may also be used. Also, the clipboardviewers 92 and 94 could be used to pull up and review a prior patientstudy without closing the study in progress, as, for example, if thediagnosing physician receives a telephone call seeking discussion of apast patient study, the diagnosing physician could call up, review, anddiscuss the past patient study, and then return the clipboard viewer toits slave functions as described above.

Control of the display on the clipboard viewer monitors may beaccomplished via controller 20 or by separate controls associated witheach of the main and clipboard viewers. When control is transferred to aslave computer, another copy of the "Viewer" software is launched in theslave computer and all functions thereof are available on the slavecomputer.

The display on the clipboard viewer monitors, as well as on the mainviewer monitor, may also be controlled by means of an array of buttonsplaced on or near the monitors. Such buttons, like controller 20,generate keyboard interrupts that provide the control of the images onthe viewer monitor. For example, buttons may be provided that trigger astepping forwards or backwards, or scrolling forwards or backwards,through the images that are selected for display on the particularmonitor. of course, other controls implemented through other interfacessuch as a conventional keyboard, mouse, touch screen, light peninterface, and the like may also be used.

As prior noted the various functions described above may be assigned toa switch or combination of switches other than the described switch orcombination of switches. In this respect, the invention is designed toprovide a "context sensitive" control in which various switchcombinations achieve different results. For example, as described above,in a dictation edit/revision mode, the physician will not be likely toneed the "toss" or "compare" functions, so that the toss buttons 46 and48 (or other switch elements) may be assigned dictation controlfunctions instead of their usual toss functions. It would also be withinthe scope of the invention to disable the image advance and retreatfunctions of a switch such as pressure switch 44 during a dictation editmode and to assign dictation control functions to that switch duringdictation edit mode. Similarly, as described above, when the "modeselection" menu is displayed, the physician is not likely to need thedictation functions, and the trigger switch 42 may be assigned modeselection functions instead of the usual dictation functions.

A further feature of the present invention is a "multimedia" recordfunction. This function will desirably be implemented automaticallywhenever the dictation trigger switch is activated, or may be limited tothe final "Conclusion" which is conventional at the end of any medicaldiagnostic dictation, or may be applied in some other summary timeperiod. The "multimedia record function" is to record the images beingreviewed by the physician at the time the dictation is recorded,enabling a later playback of the dictation with simultaneous display ofthe images that the physician reviewed at the time of the dictation. Theimage display will be synchronized to the dictation so that on playbackthe precise image being viewed at the time of the specific dictation isdisplayed. The "multimedia record function" may be implemented byrecording the file name of the image on display at the time ofparticular dictation, which may be embedded into the dictation file as alink or using other conventional techniques for slide show typepresentations, or by other file list methods.

The above described serial display system for patient images is believedto be the most efficient and user friendly system that may beimplemented. However, other possible control systems may also beimplemented in accordance with the invention. In an alternative controlsystem, using a pressure switch having additional left and right switchpositions in addition to front and back switch settings, it would bepossible to control the "Viewer" software to jump among the differentimage series. Thus instead of scrolling to the end of an image series toobtain the next series, a diagnosing physician could implement thedisplay of the next preceding series at the same image number as beingcurrently viewed by leftward pressure on the switch, or of the nextsucceeding series by rightward pressure on the switch. This would permit"lateral" movement among the various patient series. Once a new seriessequence was selected, the physician could then scroll forwards orbackwards through the series as in the above described serial displayembodiment. An adjunct clipboard viewer display might also be providedin such case to provide a matrix containing thumbnail size images of allthe images in the patient folder, arrayed in columns, with each columncontaining the images of a different series. The adjunct clipboardviewer would indicate the image being presented to the main viewer byappropriate highlighting or framing, as an aid to navigation among theimages in the study.

Although the foregoing description has described an application of acombined image review/voice dictation function in a controller 20operating in conjunction with a medical interpretation unit, the presentinvention has broader application as well. It may be implemented forexample in a legal or business environment. For example, usingcontroller 20, an attorney reviewing documents could dictate comments onthe documents (as in reviewing electronically stored raster images ofproduction documents in litigation) or revisions to a document (as inrevisions to a contract). The images which may be controlled in thisfashion may thus include graphic images, text documents, and otherelectronic files. The controller 20 in the first example would interfacewith a viewer software that controls viewing of the imaged documents.The controller 20 in the second example would interface with wordprocessing software to insert a comment or margin note in the documentfor a transcriptionist to later type in the requested changes, or wouldwork in conjunction with a speech to text conversion system to implementthe revisions. Similarly, a business person might dictate comments orresponses to electronically received faxes, and documents for typing orconversion to text.

The present invention provides an convenient and practical apparatus forreview of radiographic medical images with integrated dictation controland has better operational flexibility than any device known in the art.

It is to be appreciated that the foregoing is illustrative and notlimiting of the invention, and that various changes and modifications tothe preferred embodiments described above will be apparent to thoseskilled in the art. For example, the invention has application in otherfields where it is desired to have a handheld unit that can controlimage review with dictation abilities, such as in legal and businessfields. Such changes and modifications can be made without departingfrom the spirit and scope of the present invention, and it is thereforeintended that such changes and modifications be covered by the followingclaims.

What is claimed is:
 1. A system for manipulation and display of imagefiles, comprising:an interpretation unit comprising a computer system,said computer system being provided with at least one image displayunit, random access memory, means for digital data storage; said imagedisplay unit being provided with a main viewer and at least oneauxiliary clipboard viewer; a handheld controller, said controllerhavinga finger operated image display control for generating commandsfor controlling display of medical radiographic image files in saidimage display unit, a finger operated dictation control for generatingcommands for controlling recording and playback of audio dictation, andmeans for communicating said commands for controlling display ofdifferent medical radiographic image files, said commands forcontrolling recording and playback of audio dictation to said computersystem; means for displaying a series of image files in said mainviewer; means for selecting an image file displayed in said main viewerand displaying said image file in said clipboard viewer; and means forcomparison display, in a side by side relationship in one said clipboardviewer for visual comparison, a first series of image files beginningwith an initial first image file selected by the user with subsequentimage files automatically selected by said means for comparison display,and a second series of image files beginning with an initial secondimage file selected by the user with subsequent image files in saidsecond series of image files automatically selected by said means forcomparison display.
 2. A system in accordance with claim 1, wherein saidimage display control and said dictation control have multiplefunctions, and wherein at least some of said functions of said imagedisplay control and said dictation control are both accomplished throughcommands generated by actuation of one or more of first, second, thirdand dictation switch elements, the particular control function providedby a switch element or combination of switch elements being dependent ona mode of dictation or a mode of image display or combination of modesof dictation and image display at the time of operation of said one ormore switch elements.
 3. A system in accordance with claim 1, whereinsaid controller further comprises a microphone for receiving audiodictation and generating electrical signals corresponding to said audiodictation, and said means for communicating further comprises means forcommunicating said electrical signals corresponding to said audiodictation to said computer system, and said computer system digitallystores said electrical signals, and further, wherein said dictationcontrol is operable to control recording and playback of said digitallystored electrical signals corresponding to said audio dictation.
 4. Asystem in accordance with claim 3, further comprising means formultimedia recording and playback, wherein audio dictation stored insaid computer system is indexed to image files displayed in said mainviewer at the time when such audio dictation is recorded, wherebyplayback of said recorded audio dictation is accompanied by display ofimage files which were on display at the time of recording said audiodictation.
 5. A system in accordance with claim 1, wherein said imagedisplay control and said dictation control comprise no more than sixswitch elements.
 6. A system in accordance with claim 5, wherein saidimage display control and said dictation control comprise no more thanfour switch elements.
 7. A system in accordance with claim 1, whereinsaid main viewer and said clipboard viewer comprise separate monitors.8. A system in accordance with claim 1 wherein said main viewer and saidclipboard viewer comprise separate windows displayed on a singlemonitor.
 9. A system in accordance with claims 1, 7, or 8 wherein thereis one said main viewer and two said clipboard viewers.
 10. A system inaccordance with claim 1, wherein said means for displaying a series ofdifferent image files in said main viewer displays said image files oneimage at a time in a serial order during at least an initial display ofsaid images.
 11. A system in accordance with claim 1, wherein said imagedisplay control comprises a switch which is operable to generatecommands to transfer an image from an image file displayed in said mainviewer to at least one said clipboard viewer.
 12. A system in accordancewith claim 11, whereupon operation of said switch to generate commandsto transfer an image file displayed in said main viewer to at least onesaid clipboard viewer, said switch also generates commands to store anindication for such image file in said computer system, and whereby saidcomputer system causes the display of the image file corresponding tothe stored indication upon operation of said display control to generatecommands for displaying image files for which an indication has beenstored.
 13. A system in accordance with claim 1, wherein said imagedisplay control comprises a switch which is operable to generatecommands to cause said computer system to advance and to back up througha series of image files displayed in said image display unit.
 14. Asystem in accordance with claim 13, wherein said image display switch isresponsive to the amount of pressure applied thereto whereby lesserpressures applied thereto generate commands for advancing or backing upthrough images at a slower rate, and greater pressures applied theretogenerate commands for advancing or backing up through images at a fasterrate.
 15. A system in accordance with claim 1, wherein said computersystem stores an indication for an image file which the user of thesystem displays for a time period exceeding a predetermined time period,and whereby said computer system causes the display of the image filecorresponding to the stored indication upon operation of said displaycontrol to generate commands for displaying image files for which anindication has been stored.
 16. A system in accordance with claims 15 or12, wherein said commands for displaying image files for which anindication has been stored comprises commands for causing backing upthrough image files displayed in a display unit at a maximum rate.
 17. Asystem in accordance with claim 1, further comprising means fordisplaying in said clipboard viewer selected image files from saidseries of image files upon opening of a patient file containing saidseries of image files.
 18. A system for manipulation and display ofimage files, comprising:an interpretation unit comprising threenetworked computer systems, said computer systems being provided animage display unit, random access memory, means for digital datastorage, one of said computer systems acting as master computer and twoof said computers acting as slave computers; said image display unitscomprising a main viewer associated with said master computer andauxiliary clipboard viewers associated with said slave computers; ahandheld controller, said controller havinga finger operated imagedisplay control for generating commands for controlling display ofradiographic medical image files in at least one said image displayunit, a microphone for receiving audio dictation and generatingelectrical signals corresponding to said audio dictation, a fingeroperated dictation control operable to generate commands for recordingand playback of audio dictation received in said microphone, convertedto said electrical signals, and digitally stored in one of said computersystems, and means for communicating said commands for controllingdisplay of image files, said commands for controlling recording andplayback of audio dictation, and said electrical signals correspondingto said audio dictation to said master computer; said image displaycontrol and said dictation control having multiple functions, at leastsome of said functions of said image display control and said dictationcontrol being both accomplished through commands generated by actuationof one or more switch elements, the particular control function providedby a switch element or combination of switch elements being dependent ona mode of dictation or a mode of image display or combination of modesof dictation and image display at the time of operation of said one ormore switch elements; means for displaying a series of differentradiographic medical image files in said main viewer, said displayingmeans displaying said image files one file at a time in a serial orderduring at least an initial display of said image files; means forselecting an image file displayed in said main viewer and displayingsaid image file in at least one said clipboard viewer ; and means forcomparison display, in a side by side relationship in one said clipboardviewer for visual comparison, a first series of image files beginningwith an initial first image file selected by the user with subsequentimage files automatically selected by said means for comparison display,and a second series of image files beginning with an initial secondimage file selected by the user with subsequent image files in saidsecond series of image files automatically selected by said means forcomparison display.
 19. A system in accordance with claim 18, whereinsaid computer system stores an indication for an image file which theuser of the system displays for a time period exceeding a predeterminedtime period, and whereby said one of said computer systems causes thedisplay of the image file corresponding to the stored indication uponoperation of said display control to generate commands for displayingimage files for which an indication has been stored.
 20. A system inaccordance with claim 18, whereupon operation of said means forselecting an image file displayed in said main viewer and displayingsaid image file in at least one said clipboard viewer, said selectingand displaying means also generates commands to store an indication forsuch image file in said computer system, and whereby said computersystem causes the display of the image file corresponding to the storedindication upon operation of said display control to generate commandsfor displaying image files for which an indication has been stored. 21.A system in accordance with claims 19 or 20, wherein said commands fordisplaying image files for which an indication has been stored comprisecommands for causing backing up at a maximum rate through image filesdisplayed in a display unit.
 22. A system in accordance with claim 18,further comprising means for displaying in said clipboard viewerselected image files from said series of image files upon opening of apatient file containing said series of image files.
 23. A system inaccordance with claim 18, further comprising means for multimediarecording and playback, wherein audio dictation stored in said computersystem is indexed to image files displayed in said main viewer at thetime when such audio dictation is recorded, whereby playback of saidrecorded audio dictation is accompanied by display of image files whichwere on display at the time of recording said audio dictation.
 24. Asystem in accordance with claim 18, further comprising a light penoperable connected with said master computer to permit annotation ofimage files displayed on said main viewer.
 25. A system in accordancewith claim 18, wherein one/said clipboard viewer is positioned to theright of said main viewer, and another said clipboard viewer ispositioned to the left of said main viewer.
 26. A system in accordancewith claim 25, wherein said left and right clipboard viewers are locatedon pivotable mounts, whereby said three viewers are locatable to face acentral position, and whereby said left and right clipboard viewers arepivotable outwardly to face left and right positions.
 27. A system formanipulation and display of image files, comprising:an interpretationunit comprising a computer system, said computer system being providedwith at least one image display unit, random access memory, means fordigital data storage; said image display unit being provided with a mainviewer and at least one auxiliary clipboard viewer; a handheldcontroller, said controller havinga finger operated image displaycontrol for generating commands for controlling display of image filesin said image display unit, means for communicating said commands forcontrolling display of image files to said computer system; means fordisplaying a series of image files in said main viewer; means forselecting an image different radiographic medical file displayed in saidmain viewer and displaying said image file in said clipboard viewer; andmeans for comparison display, in a side by side relationship in one saidclipboard viewer for visual comparison, a first series of image filesbeginning with an initial first image file selected by the user withsubsequent image files automatically selected by said means forcomparison display, and a second series of image files beginning with aninitial second image file selected by the user with subsequent imagefiles in said second series of image files automatically selected bysaid means for comparison display.
 28. A system in accordance with claim27, wherein said image display control has multiple functions, andwherein at least some of said functions of said image display control isaccomplished through commands generated by actuation of one or more offirst, second, third switch elements, the particular control functionprovided by a switch element or combination of switch elements beingdependent on a mode of image display at the time of operation of saidone or more switch elements.
 29. A system in accordance with claim 27,wherein said main viewer and said clipboard viewer comprise separatemonitors.
 30. A system in accordance with claim 27 wherein said mainviewer and said clipboard viewer comprise separate windows displayed ona single monitor.
 31. A system in accordance with claim 27, whereinthere is one said main viewer and two said clipboard viewers.
 32. Asystem in accordance with claim 27, wherein said means for displaying aseries of different image files in said main viewer displays said imagefiles one image at a time in a serial order during at least an initialdisplay of said images.
 33. A system in accordance with claim 27,wherein said image display control comprises a switch which is operableto generate commands to transfer an image from an image file displayedin said main viewer to at least one said clipboard viewer.
 34. A systemin accordance with claim 33, whereupon operation of said switch togenerate commands to transfer an image file displayed in said mainviewer to at least one said clipboard viewer, said switch also generatescommands to store an indication for such image file in said computersystem, and whereby said computer system causes the display of the imagefile corresponding to the stored indication upon operation of saiddisplay control to generate commands for displaying image files forwhich an indication has been stored.
 35. A system in accordance withclaim 27, wherein said image display control comprises a switch which isoperable to generate commands to cause said computer system to advanceand to back up through a series of image files displayed in said imagedisplay unit.
 36. A system in accordance with claim 35, wherein saidimage display switch is responsive to the amount of pressure appliedthereto whereby lesser pressures applied thereto generate commands foradvancing or backing up through images at a slower rate, and greaterpressures applied thereto generate commands for advancing or backing upthrough images at a faster rate.
 37. A system in accordance with claim29, wherein said computer system stores an indication for an image filewhich the user of the system displays for a time period exceeding apredetermined time period, and whereby said computer system causes thedisplay of the image file corresponding to the stored indication uponoperation of said display control to generate commands for displayingimage files for which an indication has been stored.
 38. A system inaccordance with claims 37 or 34, wherein said commands for displayingimage files for which an indication has been stored comprises commandsfor causing backing up through image files displayed in a display unitat a maximum rate.
 39. A system in accordance with claim 27 furthercomprising means for displaying in said clipboard viewer selected imagefiles from said series of image files upon opening of a patient filecontaining said series of image files.